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Ebola Situation Report - 11 November 2015

Total confirmed cases (by week, 2015)

SUMMARY

On 7 November WHO declared that Ebola virus transmission had been stopped in Sierra Leone. The country has now entered a 90-day period of enhanced surveillance, which is scheduled to conclude on 5 February 2016. Both Liberia and Sierra Leone have now achieved objective 1 of the phase 3 response framework: to interrupt all remaining chains of Ebola virus transmission. Guinea reported no confirmed cases in the week to 8 November. A total of 4 cases have been reported from Guinea in the past 21 days, all of whom are members of the same family from the village of Kondeyah, in the subprefecture of Kaliah in Forecariah. All 69 contacts currently being followed in Guinea are located in Kaliah and are scheduled to complete their 21-day follow-up period on 14 November. However, 60 of the contacts are considered to be high risk, and one contact from Forecariah has been lost to follow up with the past 42 days. Therefore there remains a near-term risk of further cases among both registered and untraced contacts.

Robust surveillance measures are essential to ensure the rapid detection of any reintroduction or re-emergence of Ebola virus disease (EVD) in currently unaffected areas, and are central to the attainment of objective 2 of the phase 3 response framework: to manage and respond to the consequences of residual Ebola risks. To that end, Guinea, Liberia, and Sierra Leone have each put systems in place to enable members of the public to report any case of illness or death that they suspect may be related to EVD. In the week to 8 November, 24 634 such alerts were reported in Guinea, with alerts reported from all of the country’s 34 prefectures. Equivalent data are not currently available for Liberia. In Sierra Leone, 1690 alerts were reported from 12 of 14 districts in the week ending 25 October (the most recent week for which data are available).

As part of each country’s EVD surveillance strategy, blood samples or oral swabs should be collected from any individuals with clinical symptoms compatible with EVD, and from any dead person aged 5 years and above who died within 14 days of onset of symptoms and for whom cause of death has not been determined. In the week to 8, November 9 operational laboratories in Guinea tested a total of 633 new and repeat samples from 12 of the country’s 34 prefectures. 89% of all samples tested in Guinea were swabs collected from dead bodies. By contrast, 79% of the 653 new samples tested in Liberia over the same period were blood samples collected from live patients. In addition, all 15 counties in Liberia submitted samples for testing by the country’s 4 operational laboratories. 1294 new samples were collected from all 14 districts in Sierra Leone and tested by 9 operational laboratories. 77% of samples in Sierra Leone were swabs collected from dead bodies.

470 deaths in the community were reported from Guinea in the week to 8 November. This represents approximately 20% of the 2248 deaths expected based on estimates of the population and a crude mortality rate of 11 deaths per 1000 people per year. All but 4 of the 470 reported deaths were buried safely. Equivalent data are not yet available for Liberia. In Sierra Leone, 1452 reports of community deaths were received through the alert system during the week ending 25 October (the most recent week for which data are available), representing approximately 70% of the 2075 deaths expected each week based on estimates of the population and a crude mortality rate of 17 deaths per 1000 people per year.

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Not reported due to the high proportion of probable and suspected cases that are reclassified. ‡Data not available.**Cases reported before 9 May 2015 are shaded blue. Due to ongoing surveillance and retrospective validation of cases and deaths, these totals may be subject to revision. Liberia was declared free of Ebola virus transmission in the human population on 3 September 2015, and has now entered a 90-day period of heightened surveillance.†Sierra Leone was declared free of Ebola virus transmission in the human population on 7 November 2015, and has now entered a 90-day period of heightened surveillance.

PHASE 3 RESPONSE FRAMEWORK

28 599 confirmed, probable, and suspected cases have been reported in Guinea, Liberia, and Sierra Leone, with 11 299 deaths (table 1; figure 2) since the onset of the Ebola outbreak. The majority of these cases and deaths were reported between August and December 2014, after which case incidence began to decline as a result of the rapid scale-up of treatment, isolation, and safe burial capacity in the three countries. This rapid scale-up operation was known as phase 1 of the response, and was built on in the early first half of 2015 by a period of continuous refinement to surveillance, contact tracing, and community engagement interventions. This period, termed phase 2, succeeded in driving case incidence to 5 cases or fewer per week by the end of July. This marked fall in case incidence signalled a transition to a distinct third phase of the epidemic. This third phase is characterised by limited transmission across small geographical areas, combined with a low probability of high consequence incidents of re-emergence of EVD from reservoirs of viral persistence. In order to effectively interrupt remaining transmission chains and manage the residual risks posed by viral persistence, WHO, as lead agency within the Interagency Collaboration on Ebola and in coordination with national and international partners, designed the phase 3 Ebola response framework. The phase 3 response framework builds on the foundations of phase 1 and phase 2 to incorporate new developments in Ebola control, from vaccines and rapid-response teams to counselling and welfare services for survivors. The key performance indicators below detail progress made so far towards attaining the two primary objectives of the phase 3 response framework.

As of 7 November objective 1 of the Phase 3 response framework has been achieved in Liberia and Sierra Leone.

In Guinea, case incidence has remained at 5 confirmed cases or fewer per week for 16 consecutive weeks. No confirmed cases were reported in the week to 8 November. Key performance indicators for objective 1 of the phase 3 response framework in Guinea are shown in table 4.

On 8 November 69 contacts were being followed in 5 villages in the Kaliah subprefecture of Forecariah (figure 2, figure 3, table 2). Of these, 60 are considered to be high risk. All contacts are related to the cluster of 3 confirmed cases reported from a household in the village of Kondeyah in the week ending 25 October (table 3, figure 2). All contacts are scheduled to complete their 21-day follow-up period on 13 November. The confirmed case reported during the week ending 1 November was a child born in a specialised Ebola treatment centre (ETC) in the capital Conakry, and as such generated no contacts.

The Ebola ça suffit! ring vaccination trial is continuing in Guinea. All rings comprised of contacts and contacts of contacts associated with confirmed cases now receive immediate vaccination with the rVSV-ZEBOV Ebola vaccine. Previously, rings were randomly allocated to receive either immediate vaccination or vaccination 21 days after the confirmation of a case. On 1 September, the eligibility criteria for the trial were amended to allow the vaccination of children aged 6 years and above.

Locations of the 7 operational ETCs in Guinea are shown in figure 6. No health worker infections were reported in the week to 8 November (table 4).

Table 2: Cases and contacts by prefecture over the past 3 weeks

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation, and availability of laboratory results. *Data as of 8 November 2015.

Table 3: Location and epidemiological status of confirmed cases reported in the 3 weeks to 8 November 2015

*Epi-link refers to cases who were not registered as contacts of a previous case (possibly because they refused to cooperate or were untraceable), but who, after further epidemiological investigation, were found to have had contact with a previous case, OR refers to cases who are resident or are from a community with active transmission in the past 21 days. ‡Includes cases under epidemiological investigation. §A case that is identified as a community death can also be registered as a contact, or subsequently be found to have had contact with a known case (epi-link), or have no known link to a previous case.

Figure 2: Geographical distribution of new and total confirmed cases in Guinea, Liberia, and Sierra Leone

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

OBJECTIVE 2: MANAGE AND RESPOND TO THE CONSEQUENCES OF RESIDUAL RISKS​​

Key performance indicators for objective 2 of the phase 3 response framework are shown for Guinea (table 5), Liberia (table 6), and Sierra Leone (table 7). Data for several phase 3 indicators from Liberia are available at country level and will be included in subsequent situation reports.

Robust surveillance measures are essential to ensure the rapid detection of any reintroduction or re-emergence of EVD in Liberia and Sierra Leone, which have both entered 90-day periods of enhanced surveillance, and in the large areas of Guinea that have been free of EVD transmission for many months (figure 6). To that end, Guinea, Liberia, and Sierra Leone have each put systems in place to enable members of the public to report any case of illness or death that they suspect may be related to EVD. In the week to 8 November, 24 634 such alerts were reported in Guinea (table 5), with alerts reported from all of the country’s 34 prefectures. Equivalent data are not currently available for Liberia. In Sierra Leone, 1690 alerts were reported from 12 of 14 districts in the week ending 25 October (the most recent week for which data are available; table 7).

As part of each country’s EVD surveillance strategy, blood samples or oral swabs should be collected from any individuals with clinical symptoms compatible with EVD, and from any dead person aged 5 years and above who died within 14 days of onset of symptoms and for whom cause of death has not been determined. In the week to 8 November, 9 operational laboratories in Guinea tested a total of 633 new and repeat samples from 12 of the country’s 34 prefectures (figures 4 and 5). 89% of samples were collected from dead bodies. By comparison, over the same period in Liberia 653 new and repeat samples from all 15 counties were tested by the country’s 4 operational laboratories (figures 4 and 5), with 79% of samples collected from live patients. 1294 new samples from all 14 districts in Sierra Leone and tested by 9 operational laboratories (figures 4 and 5). 77% of samples were collected from dead bodies.

Figures 4 and 5 show the locations of operational laboratories in each of the 3 countries, along with the geographic distribution of blood samples taken from live patients with symptoms compatible with EVD, and of oral swabs taken collected from dead bodies. In both Guinea and Sierra Leone the majority of samples tested in the week to 8 November were oral swabs collected from dead bodies (89% and 77%, respectively). By contrast, 79% of samples tested in Liberia were blood samples collected from live patients.

470 deaths in the community were reported from Guinea in the week to 8 November (table 5). This represents approximately 20% of the 2248 deaths expected based on estimates of the population and a crude mortality rate of 11 deaths per 1000 people per year. All but 4 of the 470 reported deaths were buried safely. Equivalent data are not yet available for Liberia. In Sierra Leone, 1452 reports of community deaths were received through the alert system during the week ending 25 October (the most recent week for which data are available; table 6), representing approximately 70% of the 2075 deaths expected each week based on estimates of the population and a crude mortality rate of 17 deaths per 1000 people per year.

Capacity to isolate and treat patients with EVD remains central to the attainment of phase 3 objective 1. Phase 3 objective 2 depends on the maintenance of core standby treatment and isolation capacity. The locations of the 18 operational Ebola treatment centres (ETCs) in Guinea, Liberia, and Sierra Leone are shown in figure 6.

The deployment of rapid-response teams to quickly limit the transmission of Ebola virus following the detection of a new chain of transmission was and continues to be a cornerstone of the national response strategy in Sierra Leone. Between 14 and 28 November planning will commence for a series of simulation exercises to test national and international rapid-response capacities in the event of detection of a new case of EVD.

The unprecedented scale of the EVD outbreak in Guinea, Liberia, and Sierra Leone means there are estimated to be several thousands of survivors throughout the three countries. Survivors are rightly hailed as national heroes throughout the three countries, and have contributed enormously to many aspects of response, but they face many challenges. In addition to the stigmatization they frequently experience when they return to their own communities, survivors also face myriad health issues, from joint pains and headaches to problems with vision and poor mental health. Although there is a vibrant self-organised survivor-support community, survivors require specialized medical support as well as access to routine health care services such as ante-natal care and vaccinations and screening. With guidance from WHO and other partners, ministries of health in the three most-affected countries have plans in place to deliver a comprehensive package of services to ensure the welfare of survivors and mitigate risks posed by viral persistence.

For definitions of key performance indicators see Annex 2. Week 36 commenced on 31 August. Week 45 ended on 8 November 2015. #Alerts responded to within 24 hours. §Swabs expressed as a proportion of total number of burial alerts reported by the National Ebola Response Centre.

Figure 6: Location of Ebola treatment centres and time since last confirmed case in Guinea, Liberia, and Sierra Leone

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Data as of 5 October for the Ebola treatment centres in Liberia and Sierra Leone.

PREVIOUSLY AFFECTED COUNTRIES

Seven countries (Italy, Mali, Nigeria, Senegal, Spain, the United Kingdom, and the United States of America) have previously reported a case or cases imported from a country with widespread and intense transmission. On 6 October 2015, a patient who was reported as a case in the United Kingdom on 29 December 2014, and who later recovered, was hospitalised in the United Kingdom after developing late EVD-related complications. As of 13 October, a total of 62 close contacts had been identified in the UK for follow-up, of whom 26 have received the rVSV-ZEBOV vaccine.

PREPAREDNESS OF COUNTRIES TO RAPIDLY DETECT AND RESPOND TO AN EBOLA EXPOSURE

The introduction of an EVD case into unaffected countries remains a risk as long as cases exist in any country. With adequate preparation, however, such an introduction can be contained through a timely and effective response.

WHO’s preparedness activities aim to ensure all countries are ready to effectively and safely detect, investigate, and report potential EVD cases, and to mount an effective response. WHO provides this support through country support visits by preparedness-strengthening teams (PSTs) to help identify and prioritize gaps and needs, direct technical assistance, and provide technical guidance and tools.

Priority countries in Africa

The initial focus of support by WHO and partners is on highest priority countries – Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal—followed by high priority countries—Benin, Burkina Faso, Cameroon, Central African Republic, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Mauritania, Niger, Nigeria, South Sudan, and Togo. The criteria used to prioritize countries include the geographical proximity to affected countries, the magnitude of trade and migration links, and the relative strength of their health systems.

Since 20 October 2014, PSTs have provided technical support in Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, South Sudan, and Togo. Technical working group meetings, field visits, high-level table-top exercises, and field simulations have helped to identify key areas for improvement. Each country has a tailored plan to strengthen operational readiness.

From October 2014 to November 2015, WHO has undertaken over 290 field deployments to priority countries to assist with the implementation of national plans.

WHO provides personal protective equipment (PPE) modules containing minimum stocks to cover staff protection and other equipment needs to support 10 patient-beds for 10 days for all staff with essential functions. PPE modules have been delivered or are in the process of being delivered to all countries on the African continent. In addition, all countries have received a PPE training module.

Contingency stockpiles of PPE are in place in the United Nations Humanitarian Response Depots (UNHRD) in Accra and Dubai, and are available to any country in the event that they experience a shortage.

Ongoing follow-up support to priority countries

Following initial PST assessment missions to the priority countries in 2014, a second phase of preparedness-strengthening activities have provided support on a country-by-country basis. Planned activities are highlighted below.

With support from WHO, national and regional rapid-response team training is scheduled in Niger from 16 to 21 November.

WHO in collaboration with the Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) in implementing a surveillance-strengthening project in 6 priority countries: Benin, Gambia, Guinea-Bissau, Mauritania, Niger, Tanzania, and Togo.

A 10-day training workshop for national logisticians is planned in Senegal from 16 to 24 November.

EVD preparedness officers​

Dedicated EVD preparedness officers have been deployed to support the implementation of country preparedness plans, coordinate partners, provide a focal point for inter-agency collaboration, offer specific technical support in their respective areas of expertise, and develop capacity of national WHO staff. Preparedness officers are currently deployed to Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, and Togo.

Training, exercises, and simulations

Dedicated EVD preparedness officers have been deployed to support the implementation of country preparedness plans, coordinate partners, provide a focal point for inter-agency collaboration, offer specific technical support in their respective areas of expertise, and develop capacity of national WHO staff. Preparedness officers are currently deployed to Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, and Togo.

Surveillance and preparedness indicators

Indicators based on surveillance data, case management capacity, laboratory testing, and equipment stocks continue to be collected on a weekly basis from the four countries that share a border with affected countries: Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal.

An interactive preparedness dashboard based on the WHO EVD checklist is now available online.